Quality Improvement for Institutions
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How Improvement Activities Work

Clinicians must complete up to four Improvement Activities for a minimum of 90 days. CMS has assigned high or medium "weights" to Improvement Activities, allowing clinicians the option of completing two high-weight, four medium-weight, or a combo of one high-weight and two medium-weight activities to receive MIPS credit. Note: Groups with fewer than 15 participants or clinicians in a rural or health professional shortage area need to only complete up to two activities for a minimum of 90 days.

Learn more about Improvement Activity requirements and selection process via the CMS website.

ACC MIPS Improvement Activities

The following ACC National Quality Campaigns and clinical tools count as Improvement Activities under the Merit-Based Incentive Payment System (MIPS) – one of two ways clinicians can participate in the Centers for Medicare and Medicaid Services' Quality Payment Program.

High-Weight Improvement Activities

Medium-Weight Improvement Activities

How to Claim Participation in ACC Improvement Activities

*Note: Oct. 1, 2019 is the last date to BEGIN participation in these programs to meet the 90-day minimum.

For Clinicians

  1. Check your MIPS participation status by entering your 10-digit National Provider Identifier (NPI) number.
  2. Use the NCDR Participant Directory to find out if your associated hospital is participating in a relevant registry.
  3. If YES, the hospital Registry Site Manager can verify whether the hospital is also participating in Patient Navigator Program: Focus MI and/or Reduce the Risk: PCI Bleed. If using the Clinical Quality Coach App, clinicians can attest on their own.
    If NO, you can request that your hospital opt in to participate in one or both programs. Opting in is free, and easy instructions are available on the respective campaign websites.
  4. Clinicians associated with Patient Navigator Program: Focus MI and/or Reduce the Risk: PCI Bleed will need to report their participation through their MIPS reporting mechanism (i.e., attestation, Qualified Clinical Data Registry [QCDR], Qualified Registry, EHR, CMS web Interface) using the associated MIPS Activity ID. Clinicians can complete a short attestation form and receive a certificate of participation directly from the Patient Navigator Program: Focus MI website and the Reduce the Risk: PCI Bleed website. While documentation of an activity is not required to report participation, CMS urges participants to maintain documentation for six years.

    Note: The ACC will NOT submit data on behalf of clinicians participating in these programs. The last date to begin participation is Oct. 1, 2019!

For Hospital Administrators

  1. If you haven't already, opt in to participate in the Patient Navigator Program: Focus MI (Chest Pain – MI Registry) and/or the Reduce the Risk: PCI Bleed (CathPCI Registry). Instructions are available on the campaign websites. You will need your NCDR user name and password.
  2. Let affiliated cardiovascular clinicians know your hospital is participating in one or both ACC programs and that they can be used toward Improvement Activity credit under the Merit-Based Incentive Payment System (MIPS). (Go here, for a sample email.) Hospitals participating in the CathPCI Registry also should ensure affiliated clinicians know about the Clinical Quality Coach App as another MIPS Improvement Activity option.
  3. Eligible clinicians will need to attest to their participation in the activity as part of the 2018 reporting year. Clinicians can complete a short attestation form and receive a certificate of participation directly from the Patient Navigator Program: Focus MI website and the Reduce the Risk: PCI Bleed website.

ACC Outpatient Registries

The ACC's Outpatient Registries, the PINNACLE Registry and Diabetes Collaborative Registry, support all improvement activities. To make the process easier for participants, here are nine improvement activities that your practice likely is already doing:

  • Achieving Health Equity: Leveraging a QCDR for use of standard questionnaires
  • Care Coordination: Use of QCDR to promote standard practices, tools and processes for improvement in care coordination
  • Patient Safety and Practice Assessment: Measurement and improvement at the practice and panel level
  • Patient Safety and Practice Assessment: Use of QCDR data for ongoing practice assessment and improvements
  • Population Management: Implementation of medication management practice improvements
  • Population Management: Use of QCDR data for quality improvement, such as comparative analysis reports across patient populations
  • Population Management: Use of QCDR for feedback reports that incorporate population health
  • Population Management: Advance care planning
  • Population Management: Participation in population health research

 


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